Outcome after wait-listing for emergency liver transplantation in acute liver failure: A single centre experience☆
Introduction
Emergency liver transplantation (ELT) plays a pivotal role in the management of acute liver failure (ALF), with little impact to date from alternative therapies including liver support devices and cell transplants [1], [2]. While survival rates appear acceptable, outcomes are consistently worse than for patients undergoing elective transplantation for chronic liver disease (CLD) [3], [4], [5]. The gap in the US is seven percentage points and in Europe it is up to 15 percentage points [4], [6]. Understanding the issues driving this survival differential would be beneficial for selection and management of candidates for ELT.
Key factors that influence patient survival include the timeliness of organ availability, clinical condition of the patient at time of transplantation, quality of the donor organ and standard of intra- and post-operative care [7], [8], [9]. Organ allocation systems prioritize patients with ALF with no obvious opportunity to accelerate progression to transplantation. Supportive care protocols are sophisticated and, again, immediate significant improvement is not anticipated. Therefore, the opportunity to improve results of ELT appears to rest on an ability to recognise futility of intervention and manipulate patient/organ matching to achieve optimal results.
The most comprehensive attempt to date to address some of these issues was a study of outcomes in 1457 patients transplanted for ALF between 1998 and 2004 in the US [10]. The overall mortality was 23%, and factors identified as correlating with outcome were body mass index (BMI), serum creatinine, age and the need for assisted ventilation. Survival decreased progressively with increasing number of adverse factors present but the worst observed outcome was 42% survival in a cohort that accounted for only 2% of the study population. This study did not consider the cumulative effects of adverse graft factors of likely importance in this setting [5], [11].
We report a single-centre experience of ELT in ALF over a 10-year period with specific aims of understanding why patients listed for ELT succumbed without being transplanted, and what factors were predictive of early death once transplantation had been performed.
Section snippets
Patients and methods
This study examined all patients aged >16 years at King’s College Hospital (KCH) who were registered for ELT for the first time between January 1, 1994 and December 31, 2004. ALF was defined using criteria previously described [12], and in all patients the time from onset of jaundice to encephalopathy was less than 12 weeks. With the exception of patients with Wilsons’ disease, histopathological examination of explants or post mortem samples excluded the presence of CLD. The listing criteria
Study cohort
During the study period 1379 patients were admitted to the LITU with acute severe hepatic dysfunction, of whom 783 (57%) developed ALF with encephalopathy (HE) of grade 3 or above requiring intubation and mechanical ventilation. Three hundred and ten patients were registered for ELT. Median age of those listed was 34 years (Inter-quartile range 23–43) and 67% of the cohort were female. Two hundred and thirty-six (76%) underwent LT at a median of 1 day (IQ range 1–2, range 1–7) after listing.
Discussion
In 1990, an argument was articulated that a randomised controlled trial of liver transplantation should be carried out in ALF before its use in this setting could be adopted [16]. This never occurred and ELT was rapidly integrated into the management protocols for patients with ALF. As a consequence, decision-making paradigms evolved from natural history data and clinical outcomes. This process has been in continuous refinement based on accumulated experience and analysis of results obtained.
In
Acknowledgements
We thank to Sue Landymore and the Liver Transplant Co-ordinators at King’s College Hospital for their assistance, Juan Gonzalez for initial statistical support and Alex Hudson and Diana Pugh at UKT for supplementary data.
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The authors declare that they do not have anything to disclose regarding funding from industries or conflict of interest with respect to this manuscript.
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Joint last authors.